1. Rafael Fonseca MD Chair, Department of Medicine Mayo Clinic in AZ Multiple Myeloma: Is FISH passé? Scottsdale, Arizona Rochester, Minnesota Jacksonville, Florida Mayo Clinic College of Medicine Mayo Clinic Comprehensive Cancer Center

2. Disclosures Consulting: AMGEN, Genzyme, BMS, Otsuka, Celgene, Medtronic, Lilly, Millennium, Binding Site, Onyx, Bayer Speakers Bureaus: None Research: Cylene, Proteolix Patent for FISH based prognostication in MM - about $1500 per year Registered independent Believe in stem cell transplant Dislike wasting your time with this slide

3. Is FISH passé? Rotten FISHNigiri Toro

4. Why do risk stratification Old days Early use of bortezomib Overall prognosis New era Pt counseling (“chronic disease”) Post transplant consolidation Tandem SCT? Options for low risk cases

5. Example case 47 y.o. with new diagnosis IgA lambda MM Seen for 2 nd opinion for SCT Treated with RVD Achieved VGPR after 4 cycles Outside report FISH – negative (3 rd pull, path, flow and …) No selection No cIg Sample is obtained and has t(4;14) & -17p13

6. IgH Translocations Fonseca et al Blood 100:1417

7. Survival probability Months P<0.001 t(4;14) t(14;16) -17p13 t(4;14) t(14;16) -17p13  13 All others including t(11;14) All others including t(11;14) Poor24.7 mos Intermediate42.3 mos Good51.0 mos Poor24.7 mos Intermediate42.3 mos Good51.0 mos Fonseca et al Blood 101:4569, 2003 Molecular Prognostic Model

8. t(11;14) Myeloma

9. TC Classification Bergsagel P L et al. Blood 2005;106:296-303

10. GEP signatures Shaughnessy et al, Blood2007, 109(6), 2276-2284

11. Prognosis by Genomic Complexity Chung T-H, Mulligan G, Fonseca R, Chng WJ (2013) A Novel Measure of Chromosome Instability Can Account for Prognostic Difference in Multiple Myeloma. PLoS ONE 8(6): e66361. doi:10.1371/journal.pone.0066361 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0066361

12. So what is best to identify HR MM? Is there a perfect or best way All systems work Not one system will be 100% (so far) More powerful ones are usually smaller in number None of genetic systems combine clinical variables which may be just as important It is important to understand them!

13. Extramedullary Myeloma Graphical Overview

14. Truncating Mutation of Cereblon in Drug Resistant patient

16. Marrow collection; Practicalities MMRC # IIII III IIII Repositioning of needle Swamp analogy Contamination with peripheral blood Sufficient number of cells Purity post sort Need for viable and CD138+ cells CD138 Beads

17. PFS by Cytogenetic Category; TD 2 - 35 Day courses of consolidation Cavo M et al. Blood 2012;120:9-19

18. PFS by Cytogenetic Category; VTD 2 - 35 Day courses of consolidation Cavo M et al. Blood 2012;120:9-19

19. Landmark Start of Consolidation Cavo M et al. Blood 2012;120:9-19 VTD TD t(4;14) and no - 17p13 All

20. Effects of -17 by Treatment Arm Bortezomib Arm B (Blue-Black) Neben K et al. Blood 2012;119:940-948

21. FISH (MGUS n=184, SMM n=116, relapsed MM n=62 and PCL n=26) aCGH (newly diagnosed MM n=224, relapsed MM n=158 and HMCLs n=48) p 53 mutational status was evaluated in relapsed MM (n=84) and HMCLs (n=48) *Tiedemann et al. Leukemia. 2008; 22, 1044-1052 Studied 8 patients with 17p deletions at RR 7 did not have deletion at diagnosis Fonseca. Manuscript in preparation

22. Conclusion FISHGEPRNAseqNGSaCGH Clinical useYes No Yes Easy++ +++ ++ DNA changesYes (large) No (predicts) NoYes MutationsNo Yes No IgH TrxYesYes (spike)Yes No PowerMediumHigh??Medium Can be done with few cells YesYes +/- YesNo Clinicians find of use YesSometimes??? Clonal heterogeneity YesNoYes +/- Low level plasmacytosis YesMaybe

23. Conclusion FISH (cons) Imperfect (GEP more powerful) Technically specialized FISH (pros) Very, very practical Global Sufficient

24. Is FISH passé? Rotten FISHNigiri Toro Solid Salmon

25. Is FISH passé?